Psychiatrists Top Cash-Only MD List

by John Gever John Gever Deputy Managing Editor, MedPage Today
December 12, 2013

Action Points

Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties.

Rates of private and Medicare insurance acceptance, which had been stable in prior years, dropped sharply in the 2009-2010 period to about 55%.

Nearly 45% of psychiatrists refuse private insurance or Medicare payments for services, and more than half do not take Medicaid -- vastly higher percentages than in other specialties, researchers found.

Data from the National Ambulatory Medical Care Survey (NAMCS) showed that in 2009-2010 private, noncapitated insurance was accepted by 55.3% of psychiatrists (95% CI 46.7%-63.8%), and Medicare reimbursement was accepted by 54.8% (95% CI 46.6%-62.7%), according to Tara F. Bishop, MD, MPH, of Weill Cornell Medical College in New York City, and colleagues.

Rates of insurance acceptance across all other physicians averaged about 30 percentage points higher in 2009-2010, the NAMCS data indicated.

"These low rates of acceptance [by psychiatrists] may pose a barrier to access to mental health services," Bishop and colleagues wrote. "Policies to improve access to timely psychiatric care may be limited because many psychiatrists do not accept insurance."

But with nearly half of psychiatrists apparently operating on a cash-only basis, the legislation's impact on overall uptake of mental health services may be less than expected.

From 2005 to 2010, the NAMCS included from 1,058 to 1,357 physician respondents each year (mean 1,250), of whom 5.5% were psychiatrists, Bishop and colleagues indicated. The survey collects data on a wide range of physician and patient characteristics, including the types of insurance physicians accept.

The researchers excluded private capitated insurance from their analysis "because only a very small proportion of psychiatrists" participate in such plans.

Rates of insurance acceptance remained fairly stable during the first two periods. From 2005-2006 to 2007-2008, rates of private and Medicare acceptance fell slightly, from just over 70% to just under. Rates in both categories then dropped sharply in the 2009-2010 period to about 55% (P≤0.01).

A much smaller decline was seen in insurance acceptance rates among nonpsychiatrist physicians. Private insurance acceptance stood at 93.1% (95% CI 91/5%-94.5%) in 2005-2006, dropping about five points to 88.7% (95% CI 86.4%-90.7%, P<0.001) in the most recent period.

Rates of Medicare acceptance were similar (87.8% in the first period, 86.1% in the third).

For Medicaid acceptance, psychiatrists showed a smaller and statistically insignificant decrease: from 49.3% (95% CI 41.2%-57.5%) in 2005-2006 to 43.1% (95% CI 34.9%-51.7%) in 2009-2010. No meaningful change was seen among nonpsychiatrists, whose acceptance rate hovered just over 70% through all three periods.

"To our knowledge, no prior studies have documented such a striking difference in insurance acceptance rates between psychiatrists and physicians in other specialties," Bishop and colleagues wrote.

Although the survey questionnaire does not ask about reasons for accepting insurance or not, the researchers offered several possible explanations.

One is that recent trends in the psychiatrist workforce may mean that those now in practice "have so much demand for their services that they do not need to accept insurance," Bishop and colleagues speculated. They cited a 2011 study that found a 14% decline in the number of newly minted psychiatrists from 2000 to 2008, and another indicating that more than half of practicing psychiatrists are 55 or older -- the collective result of which may be that "the supply of psychiatrists cannot meet the demand."

Also, the NAMCS excludes physicians practicing in hospital outpatient clinics. Most psychiatrists working out of private offices are in solo practice, the researchers noted, and therefore "may have little incentive to hire staff to interact with insurance companies," they wrote.

Another explanation is that reimbursement rates set by insurers -- private as well as public -- may be too low to adequately compensate psychiatrists for the time-consuming care required by their patients. Bishop and colleagues suggested that patients with uncomplicated issues are often managed in primary care, usually by pharmacotherapy, in visits lasting 10 to 20 minutes and with reimbursements set accordingly. Psychiatrists who treat complex cases and/or who provide psychotherapy may be left out in the cold.

Bishop and colleagues cautioned that their study had limitations in addition to the NAMCS exclusions. Only about 60 psychiatrists were included in the survey each year, leading to the relatively broad 95% confidence intervals.

Also, patient access to insurance reimbursement for psychiatric care may be greater than the study data indicated -- patients can often get partial reimbursement for out-of-network psychiatric care by submitting bills themselves to their insurers, the researchers noted.

The study had no specific external funding. Individual authors received support by the National Institutes of Health and the Department of Veterans Affairs.

Authors declared they had no relevant financial interests.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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